Continuing versus Withholding Renin-Angiotensin-Aldosterone System Antagonists Before Noncardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND

It remains unclear whether to continue or withdraw angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEI) before noncardiac surgery to reduce perioperative morbidity. This systematic review and meta-analysis aimed to analyze the consequences of continuing ARB or ACEi in the incidence of intraoperative hypotension and postoperative complications.

METHODS

This systematic review and meta-analysis followed the PRISMA 2020 guidelines and was registered in the PROSPERO database. We conducted a comprehensive search in several bibliographic databases for studies comparing continuing versus withholding renin angiotensin aldosterone system antagonists before noncardiac surgery. Primary outcomes included the incidence of intraoperative hypotension, while secondary outcomes covered the intraoperative use of the vasoactive agent, the incidence of severe hypotension, intraoperative and postoperative hypertension, the incidence of acute kidney injury (AKI), 30-day postoperative all-cause mortality, and the incidence of major cardiocerebral events (MACCE).

RESULTS

Five randomized controlled trials, three nonrandomized controlled trials, and four retrospective case-control studies were included that involved 50184 patients. Meta-analysis revealed that continuing ACEI or ARBs before surgery increased the incidence of intraoperative hypotension (OR = 1.96, 95%CI [1.30, 2.96] p=0.001). Heterogeneity was substantial across studies but was significantly reduced in subgroup analyses. Furthermore, the use of vasoactive agents and the incidence of severe hypotension were significantly higher in the continuing group. No significant differences in intraoperative hypertension and the incidence of AKI and MACCE at 30 days after the operation.

CONCLUSIONS

Continued ACEI or ARBs before non-cardiac surgery increases the incidence of intraoperative hypotension, without reducing the incidence of both AKI and MACCE postoperatively. More research is necessary to explore the appropriate perioperative management of ACE-I and ARB.